When are special reports typically required?

Special reports are typically required with the use of unlisted codes. When a healthcare provider performs a service that is not specifically described by a code in the Current Procedural Terminology (CPT) manual, they must provide a special report to justify the use of that unlisted code. This report should detail the nature of the service or procedure performed, the reason it was necessary, and any other relevant information to ensure that the coding accurately reflects the care provided.

The need for special reports stems from the fact that unlisted codes do not describe the procedure in the available coding system, making it essential for the provider to explain the circumstances and rationale for using that specific code. This helps insurance companies understand the context and approve appropriate reimbursement.

By contrast, standard coding procedures do not generally require special reports because they are well defined within the coding structure. Similarly, audits are assessments of coding practices and may not involve special reports unless unlisted codes are applied. Finally, not all surgical procedures necessitate special reports; only those coded using unlisted codes require such documentation.